Acs Tqip Geriatric Trauma Management Guidelines

ACS TQIP GERIATRIC TRAUMA MANAGEMENT GUIDELINES

Released October 2013 Table of Contents Background and Introduction...... 3 Trauma Team Activation...... 3 Initial Evaluation...... 3 Specialized Geriatric Inpatient Care...... 5 Patient Decision-Making Capacity and Care Preferences...... 6 Discharge...... 7 Appendix I...... 9 Beers Criteria for Potentially Inappropriate Medication Use in Older Adults Appendix II...... 17 Legally Relevant Criteria for Decision-Making Capacity and Approaches for Assessment of the Patient Screening for Depression Screening for Alcohol and Substance Abuse Assessing Baseline and Current Functional Status in Ambulatory Patients Assessing Gait and Mobility Impairment and Fall Risk in Ambulatory Patients Frailty Score: Operational Definition Frailty Score Screening for Nutritional Risk Bibliography...... 21 References...... 27 Expert Panel...... 28

2 Background and Initial Evaluation Introduction The primary survey for the elderly is the same as for any injured patient, but the secondary Traumatic injury in the geriatric population is survey should emphasize the following: increasing in prevalence and is associated with higher mortality and complication rates compared zz Determine medications that affect with younger patients. An appreciation for the initial evaluation and care. decreased physical reserve, presence of various comorbid diseases, and increased risk of elderly- Coumadin specific complications such as delirium that are Clopidogrel more common in elderly patients has prompted Other anticoagulants development of elderly-specific care protocols within the multidisciplinary trauma service model. The aim ASA is to employ better risk assessment, adherence to Beta blockers key preventive strategies, active surveillance, and prompt recognition and treatment of complications ACE inhibitors when they occur to reduce mortality and morbidity zz Consider common, acute, nontraumatic in this patient population. This document serves events that could complicate the to consolidate recommendations from existing patient’s presentation, including: guidelines to provide concise, evidence-based, expert panel rated lists of protocols and practices Acute coronary syndrome (EKG) to improve trauma care among elderly patients. Hypovolemia/dehydration Urinary tract infection Pneumonia Trauma Team Activation Acute renal failure Cerebrovascular event Elderly patients can experience significant injury in spite of a relatively trivial mechanism. Because Syncope of altered baseline vital signs due to changes associated with aging, preexisting disease (for zz Lab assessment: example, hypertension), or medications (for example, Hypoperfusion is often underappreciated in beta-blockers), the physiologic response to injury the elderly. Base deficit should be assessed might differ from that seen in younger patients. expediently to identify those patients in occult Alterations in mentation may be attributed to shock who need resuscitation, abbreviated dementia or delirium, leading to the potential for evaluation, and admission to an intensive care late recognition of shock or traumatic brain injury. unit. The following panel of laboratory studies These factors increase the risk for undertriage is suggested for all elderly patients with injury: by both emergency medical services (EMS) and emergency department (ED) personnel. Undertriage Lactic acid or blood gas (arterial or of the elderly is associated with a two-fold increase venous) for baseline base deficit in the risk of death. To mitigate late recognition of significant injuries, a lower threshold for trauma team PT/PTT/INR activation should be used for elderly trauma patients. Renal function (BUN, Cr, estimated GFR) In many cases, this approach would require elevating Blood alcohol level the level of activation by one tier based on age. Urine toxicology screen zz Ensure trauma team activation for Serum electrolytes all elderly injured patients meeting trauma criteria (first or second tier).

3 zz Imaging: zz Anticoagulation reversal:

Occult injuries are common in the elderly. This field and the availability of products for Initial imaging should include liberal use of reversal are also changing rapidly. A protocol computed tomography (CT) scanning for to rapid anticoagulation reversal is associated blunt injury. While the liberal use of CT scan with improved outcomes in injured patients. imaging has become controversial because of concerns of radiation exposure and cost, It is suggested that a rapid anticoagulation occult injuries are common in the elderly reversal protocol be developed in each and radiation exposure is of minimal risk. center based on the availability of products, local costs, and preferences. In general, the Imaging should include all CT scans needed following principles should be applied: to rule out injury in appropriate areas at risk. Warfarin reversal: While reversal of zz Anticoagulation assessment and reversal: warfarin was typically managed using a combination of vitamin K and plasma in The frequent use of warfarin, antiplatelet the past, the availability and assessment of agents (for example, clopidogrel, aspirin), direct newer prothrombin complex concentrates thrombin inhibitors (for example, dabigatran), (PCC) have provided other options. PCCs and direct factor Xa inhibitors (for example, available as four-factor concentrates (II, rivaroxaban) in the elderly puts them at higher VII, IX, and X) can reverse the effects of risk for significant bleeding events, even in the warfarin rapidly and are considered the context of minor injury. Additionally, with the standard in most countries other than exception of warfarin, where anticoagulant effect the U.S. At this time, only three-factor parallels the international normalized ratio (INR), concentrates are available in the U.S. an assessment of the level of anticoagulation is These PCCs lack factor VII and must not possible with laboratory investigations that either be given with plasma or rVIIa. are routinely part of the initial evaluation of the injured patient. This field is changing rapidly, Dabigatran: There is no means of reversing but the following general principles apply: dabigatran. While dialysis can be used, it is often not practical in the context of A normal INR should exclude the presence acute resuscitation. As dabigatran is an of significant levels of dabigatran or inhibitor of direct thrombin inhibitor, other novel anticoagulants in most, but administration of plasma is not effective. not all, patients; however, note that the Rivaroxaban: Like dabigatran there is no INR might be only minimally increased agent that directly reverses the effects in the presence of therapeutic doses of of this factor Xa inhibitor. However, dabigatran. Rivaroxaban increases the INR early studies suggest that the effect at therapeutic levels, but the effects are might in part be reversed by PCCs. not equivalent to target levels of warfarin. Clopidrogel, aspirin: There are no Partial thromboplastin time (PTT) might agents that directly reverse the effects be slightly prolonged with dabigatran, of these platelet antagonists. DDAVP or depending on the instruments/reagents platelet transfusion can be considered used for laboratory assessment. Rivaroxaban in the face of significant bleeding. might cause mild PTT prolongations in most patients with therapeutic levels. Other tests: Thrombin time: Dabigatran increases the thrombin time (TT). A normal TT excludes Dabigatran; however, note that Rivaroxaban does not prolong the TT. Thromboelastography (TEG): TEG is useful in identifying the presence of dabigatran or ribaroxaban effect. TEG will also identify the presence of effects of platelet inhibitors like clopidrogel.

4 zz If the response to two or more of the following questions is “yes,” geriatric Specialized Geriatric consultation should be obtained:

Inpatient Care Before you were injured, did you need someone to help you on a regular basis? A proactive geriatric consultation is one in which an individual with expertise in the management of the Since the injury, have you needed more geriatric patient (most often a geriatrician) evaluates help than usual to take care of yourself? a patient early following hospitalization and prior to Have you been hospitalized for one or complications developing. This evaluation includes more nights during the past six months? a comprehensive geriatric assessment (CGA), which is a multidimensional, multidisciplinary diagnostic In general, do you have instrument designed to collect data on the medical, problems seeing well? psychosocial, and functional capabilities and In general, do you have serious limitations of elderly patients. The information problems with your memory? derived from this assessment assists in developing Do you take more than three treatment and follow-up plans. In 22 randomized different medications every day? trials including more than 10,000 patients, a CGA followed by appropriate treatment and follow- Geriatric trauma patients are at particular risk up increases a patient’s likelihood of being alive for medication-related adverse events. and in his or her own home at one year following z discharge by 25 percent. In trauma, proactive z Establish past medication history. geriatric consultation has been associated with Attempt to communicate with the patient’s fewer episodes of delirium, fewer in-hospital falls, immediate family and physician. lesser likelihood of discharge to a long-term care facility, and a shorter length of stay. An alternate Document the patient’s complete approach is to concentrate care of the geriatric medication list, including over-the-counter patient so that care pathways are developed and and complementary/alternative medication. expertise accrues to benefit the patient. For example, zz Use the following geriatric medication Mangram et al developed a geriatric trauma service prescribing recommendations: (“G-60 service”) in which all patients age > 60 were admitted. This service worked in collaboration Follow Beers Criteria. Use Beers with a medical hospitalist, physiatrist, physical/ Criteria in decision making about occupational therapist, respiratory therapist, pharmacotherapy. See Appendix 1. nursing supervisor with geriatric expertise, social worker, nutritionist, pharmacist, and a palliative Discontinue nonessential medications. care specialist. Implementation of this service Continue medications with withdrawal was associated with a reduction in time to the potential, including selective serotonin operating room (OR), hospital and ICU length reuptake inhibitors (SSRIs), tricyclic of stay, and rates of several complications. antidepressants, benzodiazepines, antipsychotics, monoamine oxidase zz Develop criteria for early geriatric inhibitors (MAOIs), beta blockers, consultation and geriatric expertise on the clonidine, statins, and corticosteroids. multidisciplinary trauma care team. Continue β-blocker or start if indicated. Where limitations with geriatrician resources Continue statins when appropriate. impede routine geriatric consultation, the following screening criteria may identify patients most Adjust doses of medications for renal likely to benefit from geriatric consultation. These function based on glomerular filtration rate. criteria were adapted from the Identification of Seniors at Risk (ISAR) screening tool. A positive ISAR (>=2) has been associated with a greater likelihood of functional decline, nursing home admission, long-term hospitalization, or death.

5 Effective pain management can be a central determinant of success in the drive to improve pulmonary and toilet functions, Patient Decision- optimize mobility, and mitigate delirium. Making Capacity and zz The following pain medication strategies are recommended: Care Preferences More than 40 percent of patients require decision Use elderly-appropriate making near the end of life, with 70 percent of those medications and dose. patients lacking decision-making capacity. Injured Avoid benzodiazepines. patients and their families are suddenly thrust into Monitor use of narcotics; consider a situation where health and subsequent quality of early implementation of patient- life are placed in jeopardy. Unfortunately, decision controlled analgesia. making and treatment preferences may not have been established. The patient’s current condition Consider early use of nonnarcotics, and prognosis should be clearly communicated to including NSAIDs, adjuncts, and tramadol. the patient and their family. Important decisions Epidural algesia may be preferable to that will need to be made regarding treatment other means for patients with multiple must be emphasized so that patient treatment rib fractures to avoid respiratory failure. preferences can be considered. Treatment burden and potential functional outcome play a large role It is important to obtain preinjury chronic in the decision-making process. In cases of impaired medical conditions and functional status soon cognition, identification of the proxy decision maker after admission. While it may not be possible is of importance, while realizing that surrogates to obtain this information immediately, it is may not always be fully aware of the patient’s imperative to do so as part of the tertiary survey treatment preferences. Liberal use of palliative care to facilitate hospital care and discharge planning. services can help with complex decision making. The compilation of this information and the development of a subsequent care plan may be zz Discuss with family, surrogates, and performed by a formal geriatrician consult or by the health care team and document in adding personnel with geriatric expertise to the the medical record the following: multidisciplinary trauma team. See Appendix 2. Patient’s priorities and preferences zz Establish past history of elderly- regarding treatment options (including specific comorbidities, including: operative and nonoperative alternatives)

Pulmonary disease Postinjury risks of complications, mortality, and temporary/ Chronic renal failure permanent functional decline Chronic anemia Advance directives or living will and Depression how these will affect initial care and life- sustaining preferences, including mechanical Baseline cognitive impairment ventilation, cardiopulmonary resuscitation Baseline functional impairment (CPR), hemodialysis, blood transfusion, Baseline frailty scores permanent enteral feeding, and transition to comfort care should complications occur Baseline nutritional status Identify surrogate decision maker Alcohol, tobacco, drug abuse or dependence (benzodiazepines, oxycodone) Make liberal use of palliative care options Thyroid dysfunction In appropriate setting, present hospice as a positive active treatment Glucose intolerance Decubitus ulcer

6 zz Hold a family meeting within 72 hours The elderly may have limited reserve to of admission to discuss goals of care. tolerate changes in intravascular volume. It is important to prevent or correct occult Delirium is common in elderly patients after hypovolemia as well as volume overload. injury and is associated with increased morbidity and mortality. It is important to assess the zz Monitor the patient’s fluid status patient’s baseline cognitive function, assess with the following: risk factors for delirium, and monitor for signs and symptoms of delirium on a daily basis. Daily fluid inputs and outputs The Mini-Cog is a short assessment tool that Daily weights can be used for this purpose. Knowledgeable informants, such as family, may need to assist Consider central venous pressure monitoring in providing preinjury baseline status. Consider noninvasive cardiac output in the ICU zz Regularly evaluate and address delirium risk factors: Postoperative and in-hospital complications contribute to extended length of stay, functional Cognitive impairment and dementia outcome, and cost for the trauma patient. In Depression traumatically injured patients, functional ability, including gait and fall risk, should be assessed as Alcohol use early as possible and compared with established Polypharmacy and psychotropic medications baseline function. Early mobilization and the use Poor nutrition of standardized care bundles can help prevent development of many iatrogenic complications. Hearing and vision impairment zz Protect patients from iatrogenic zz Regularly monitor for reversible complications and functional decline: causes of delirium: Develop a plan for early mobilization. Ensure Wake-sleep cycle disturbances ambulation within 48 hours of admission. and sleep deprivation Assess for fall risk and address. Immobilization Institute aspiration precautions: Hypoxia Infection Head of bed elevation at all times with repositioning. Uncontrolled pain Sitting upright while eating and two Renal insufficiency, dehydration, hours after completion of eating. and electrolyte abnormalities Evaluate for swallowing deficits. Urinary retention or presence of urinary catheter Perform chest physical therapy by incentive Fecal impaction or constipation spirometer or deep breathing exercises. Use of restraints Place on bowel regimen if given opiates. Perform screening for:

Presence for pressure ulcers with Braden or Norton scale within 24 hours of diagnosis. Daily documentation of skin integrity.

7 zz Communicate the results of the hospitalization to the patient’s primary care physician (PCP). Discharge Provide PCP with the discharge summary. Verbal communication with the PCP can be very helpful. Traumatic injury is a sentinel event that can precipitate a trajectory of functional decline in zz Provide the receiving facility with a discharge older patients. Studies show that the majority (up summary prior to the patient’s departure to 88 percent) of seriously injured older patients fail from the hospital. Verbal communication with to return to their previous level of independence the receiving facility can be very helpful. and function, with many requiring long-term nursing home placement. In addition to medical zz Arrange for a home health visit or comorbidities that accompany aging, psychosocial follow-up phone call within one to issues (for example, availability of a caregiver, home three days of discharge to assess: safety) complicate the hospital and postdischarge care of these patients. Despite the magnitude Pain control of the problem, little is known about how to Tolerance of food, liquids improve functional outcomes of injured elderly. Ability to ambulate zz Begin developing a plan for transition Mental status to posthospital care or special unit care in the immediate postinjury period. Understanding of postdischarge instructions/medications zz Assess the following discharge planning issues early during hospitalization:

Home environment, social support, and possible needs for medical equipment and/or home health services Patient acceptance/denial of nursing home or skilled nursing facility placement

zz Provide the patient or caregiver with a written discharge document, including:

Discharge diagnosis Medications and clear dosing instructions and possible reactions Documentation of reconciliation between outpatient and inpatient medications Directions for wound care Instructions for diet (nutrition plan) and mobility Needs for physical and occupational therapy Contact information for the patient’s continuity physician or clinic Establish an appointment with continuity physician, specialty physicians, or clinic Clear documentation of incidental findings that mandate follow-up Documentation of follow-up appointment/telephone contact with the surgeon six weeks after surgery Documentation of pending laboratory tests or diagnostic studies, if applicable

8 Appendix 1

Beers Criteria for Potentially Inappropriate Medication Use in Older Adults 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults1 Organ System/ Strength Therapeutic Quality of of Recom- Category/Drug(s) Rationale Recommendation Evidence mendation Anticholinergics (excludes TCAs) First-generation Highly anticholinergic; clearance Avoid Hydroxyzine Strong antihistamines (as single reduced with advanced age, and agent or as part of and tolerance develops when promethazine: combination products) used as hypnotic; increased High zz Brompheniramine risk of confusion, dry mouth, constipation, and other zz Carbinoxamine All others: anticholinergic effects/toxicity zz Chlorpheniramine Moderate zz Clemastine Use of diphenhydramine in zz Cyproheptadine special situations such as acute zz Dexbrompheniramine treatment of severe allergic zz Dexchlorpheniramine reaction may be appropriate zz Diphenhydramine (oral) zz Doxylamine zz Hydroxyzine zz Promethazine zz Triprolidine Anti-Parkinson agents Not recommended for Avoid Moderate Strong zz Benztropine (oral) prevention of extrapyramidal zz Trihexyphenidyl symptoms with antipsychotics; more effective agents available for treatment of Parkinson disease Antispasmodics Highly anticholinergic, Avoid except Moderate Strong zz Belladonna alkaloids uncertain effectiveness in short-term zz Clidinium- palliative care chlordiazepoxide to decrease oral zz Dicyclomine secretions zz Hyoscyamine zz Propantheline zz Scopolamine Antithrombotics Dipyridamole, oral short- May cause orthostatic Avoid Moderate Strong acting* (does not apply hypotension; more effective to the extended-release alternatives available; IV combination with aspirin) form acceptable for use in cardiac stress testing Ticlopidine* Safer, effective Avoid Moderate Strong alternatives available Antiinfective Nitrofurantoin Potential for pulmonary toxicity; Avoid for long- Moderate Strong safer alternatives available; lack term suppression; of efficacy in patients with CrCl avoid in patients <60 mL/min due to inadequate with CrCl <60 drug concentration in the urine mL/min

9 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults1 Organ System/ Strength Therapeutic Quality of of Recom- Category/Drug(s) Rationale Recommendation Evidence mendation Cardiovascular

Alpha1 blockers High risk of orthostatic Avoid use as an Moderate Strong zz Doxazosin hypotension; not recommended antihypertensive zz Prazosin as routine treatment for zz Terazosin hypertension; alternative agents have superior risk/benefit profile Alpha blockers, central High risk of adverse CNS effects; Avoid clonidine Low Strong zz Clonidine may cause bradycardia and as a first-line zz Guanabenz* orthostatic hypotension; not antihypertensive zz Guanfacine* recommended as routine zz Methyldopa* treatment for hypertension Avoid others zz Reserpine as listed (>0.1 mg/day)* Antiarrhythmic drugs Data suggest that rate control Avoid High Strong (Class Ia, Ic, III) yields better balance of benefits antiarrhythmic zz Amiodarone and harms than rhythm drugs as first- zz Dofetilide control for most older adults line treatment of zz Dronedarone atrial fibrillation zz Flecainide Amiodarone is associated zz Ibutilide with multiple toxicities, zz Procainamide including thyroid disease, zz Propafenone pulmonary disorders, and zz Quinidine QT interval prolongation zz Sotalol Disopyramide* Disopyramide is a potent Avoid Low Strong negative inotrope and therefore may induce heart failure in older adults; strongly anticholinergic; other antiarrhythmic drugs preferred Dronedarone Worse outcomes have Avoid in patients Moderate Strong been reported in patients with permanent taking dronedarone who atrial fibrillation have permanent atrial or heart failure fibrillation or heart failure

In general, rate control is preferred over rhythm control for atrial fibrillation Digoxin >0.125 mg/day In heart failure, higher dosages Avoid Moderate Strong associated with no additional benefit and may increase risk of toxicity; decreased renal clearance may lead to increased risk of toxic effects Nifedipine, immediate Potential for hypotension; Avoid High Strong release* risk of precipitating myocardial ischemia

10 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults1 Organ System/ Strength Therapeutic Quality of of Recom- Category/Drug(s) Rationale Recommendation Evidence mendation Spironolactone >25 mg/day In heart failure, the risk of Avoid in patients Moderate Strong hyperkalemia is higher in older with heart failure adults if taking >25 mg/day or with a CrCl <30 mL/min Central Nervous System Tertiary TCAs, alone Highly anticholinergic, Avoid High Strong or in combination: sedating, and causes orthostatic zz Amitriptyline hypotension; the safety zz Chlordiazepoxide- profile of low-dose doxepin amitriptyline (≤6 mg/day) is comparable zz Clomipramine to that of placebo zz Doxepin >6 mg/day zz Imipramine zz Perphenazine- amitriptyline zz Trimipramine Antipsychotics, first- Increased risk of cerebrovascular Avoid use for Moderate Strong (conventional) and second- accident (stroke) and mortality behavioral (atypical) generation (see in persons with dementia problems of Table First- and Second- dementia unless Generation Antipsychotics nonpharmacologic on page 15 for full list) options have failed and patient is threat to self or others Thioridazine Highly anticholinergic Avoid Moderate Strong Mesoridazine and greater risk of QT- interval prolongation Barbiturates High rate of physical Avoid High Strong zz Amobarbital* dependence; tolerance to zz Butabarbital* sleep benefits; greater risk of zz Butalbital overdose at low dosages zz Mephobarbital* zz Pentobarbital* zz Phenobarbital zz Secobarbital*

11 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults1 Organ System/ Strength Therapeutic Quality of of Recom- Category/Drug(s) Rationale Recommendation Evidence mendation Benzodiazepines Older adults have increased Avoid High Strong SHORT- AND INTERMEDIATE- sensitivity to benzodiazepines benzodiazepines ACTING: and decreased metabolism (any type) for of long-acting agents; in treatment zz Alprazolam general, all benzodiazepines of insomnia, z z Estazolam increase risk of cognitive agitation, or zz Lorazepam impairment, delirium, falls, delirium zz Oxazepam fractures, and motor vehicle zz Temazepam accidents in older adults zz Triazolam May be appropriate for seizure LONG-ACTING: disorders, rapid eye movement zz Chlorazepate sleep disorders, benzodiazepine zz Chlordiazepoxide withdrawal, ethanol withdrawal, zz Chlordiazepoxide- severe generalized anxiety amitriptyline disorder, periprocedural zz Clidinium- anesthesia, end-of-life care chlordiazepoxide zz Clonazepam zz Diazepam zz Flurazepam zz Quazepam Chloral hydrate* Tolerance occurs within 10 Avoid Low Strong days and risk outweighs the benefits in light of overdose with doses only 3 times the recommended dose Meprobamate High rate of physical Avoid Moderate Strong dependence; very sedating Nonbenzodiazepine Benzodiazepine-receptor Avoid chronic Moderate Strong hypnotics agonists that have adverse use (>90 days) events similar to those of zz Eszopiclone benzodiazepines in older zz Zolpidem adults (for example, delirium, zz Zaleplon falls, fractures); minimal improvement in sleep latency and duration Ergot mesylates* Lack of efficacy Avoid High Strong Isoxsuprine* Endocrine Androgens Potential for cardiac problems Avoid unless Moderate Weak zz Methyltestosterone* and contraindicated in men indicated for zz Testosterone with prostate cancer moderate to severe hypogonadism Desiccated thyroid Concerns about cardiac effects; Avoid Low Strong safer alternatives available

12 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults1 Organ System/ Strength Therapeutic Quality of of Recom- Category/Drug(s) Rationale Recommendation Evidence mendation Estrogens with or Evidence of carcinogenic Avoid oral and Oral and Oral and without progestins potential (breast and topical patch patch: High patch: Strong endometrium); lack of Topical vaginal Topical: Topical: cardioprotective effect cream: Acceptable Moderate Weak and cognitive protection to use low-dose in older women intravaginal Evidence that vaginal estrogens estrogen for the for treatment of vaginal management dryness is safe and effective of dyspareunia, in women with breast cancer, lower urinary especially at dosages of tract infections, estradiol <25 mcg twice weekly and other vaginal symptoms Growth hormone Impact on body composition Avoid, except High Strong is small and associated with as hormone edema, arthralgia, carpal tunnel replacement syndrome, gynecomastia, following pituitary impaired fasting glucose gland removal Insulin, sliding scale Higher risk of hypoglycemia Avoid Moderate Strong without improvement in hyperglycemia management regardless of care setting Megestrol Minimal effect on weight; Avoid Moderate Strong increases risk of thrombotic events and possibly death in older adults Sulfonylureas, long-duration Chlorpropamide: Prolonged Avoid High Strong half-life in older adults; zz Chlorpropamide can cause prolonged zz Glyburide hypoglycemia; causes SIADH Glyburide: higher risk of severe prolonged hypoglycemia in older adults Gastrointestinal Metoclopramide Can cause extrapyramidal Avoid, unless for Moderate Strong effects including tardive gastroparesis dyskinesia; risk may be further increased in frail older adult. Mineral oil, given orally Potential for aspiration Avoid Moderate Strong and adverse effects; safer alternatives available Trimethobenzamide One of the least effective Avoid Moderate Strong antiemetic drugs; can cause extrapyramidal adverse effects Pain Medications Meperidine Not an effective oral analgesic Avoid High Strong in dosages commonly used; may cause neurotoxicity; safer alternatives available

13 2012 AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults1 Organ System/ Strength Therapeutic Quality of of Recom- Category/Drug(s) Rationale Recommendation Evidence mendation Non–COX-selective Increases risk of GI bleeding/ Avoid chronic All others: Strong NSAIDs, oral peptic ulcer disease in high- use unless other Moderate zz Aspirin >325 mg/day risk groups, including those alternatives are zz Diclofenac >75 years old or taking oral not effective and zz Diflunisal or parenteral corticosteroids, patient can take zz Etodolac anticoagulants, or antiplatelet gastroprotective zz Fenoprofen agents; use of proton pump agent (proton- zz Ibuprofen inhibitor or misoprostol reduces pump inhibitor zz Ketoprofen but does not eliminate risk; or misoprostol) zz Meclofenamate upper GI ulcers, gross bleeding, zz Mefenamic acid or perforation caused by zz Meloxicam NSAIDs occur in approximately zz Nabumetone 1% of patients treated for zz Naproxen 3–6 months, and in about zz Oxaprozin 2%–4% of patients treated for zz Piroxicam 1 year; these trends continue zz Sulindac with longer duration of use zz Tolmetin

Indomethacin Increases risk of GI bleeding/ Avoid Indomethacin: Strong Ketorolac, includes parenteral peptic ulcer disease in Moderate high-risk groups (see above Ketorolac: High non–COX-selective NSAIDs) Of all the NSAIDs, indomethacin has most adverse effects Pentazocine* Opioid analgesic that causes Avoid Low Strong CNS adverse effects, including confusion and hallucinations, more commonly than other narcotic drugs; is also a mixed agonist and antagonist; safer alternatives available zz Skeletal muscle relaxants Most muscle relaxants poorly Avoid Moderate Strong zz Carisoprodol tolerated by older adults zz Chlorzoxazone because of anticholinergic zz Cyclobenzaprine adverse effects, sedation, zz Metaxalone increased risk of fractures; zz Methocarbamol effectiveness at dosages zz Orphenadrine tolerated by older adults is questionable. *Infrequently used drugs ABBREVIATIONS: ACEI, angiotensin converting-enzyme inhibitors; ARB, angiotensin receptor blockers; CNS, central nervous system; COX, cyclooxygenase; CrCl, creatinine clearance; GI, gastrointestinal; NSAIDs, nonsteroidal antiinflammatory drugs; SIADH, syndrome of inappropriate antidiuretic hormone secretion; TCAs, tricyclic antidepressants.

14 2012 AGS Beers Criteria for Potentially Inappropriate Medications to Be Used with Caution in Older Adults1 Strength Quality of of Recom- Drug(s) Rationale Recommendation Evidence mendation Aspirin for primary Lack of evidence of benefit Use with caution Low Weak prevention of cardiac events versus risk in individuals in adults ≥80 ≥80 years old years old Dabigatran Increased risk of bleeding Use with caution Moderate Weak compared with warfarin in in adults ≥75 adults ≥75 years old; lack years old or if CrCl of evidence for efficacy <30 mL/min and safety in patients with CrCl <30 mL/min Prasugrel Increased risk of bleeding in Use with caution Moderate Weak older adults; risk may be offset in adults ≥75 by benefit in highest-risk years old older patients (for example, those with prior myocardial infarction or diabetes) Antipsychotics May exacerbate or cause Use with caution Moderate Strong Carbamazepine SIADH or hyponatremia; need to monitor sodium Carboplatin level closely when starting Cisplatin or changing dosages in older adults due to increased risk Mirtazapine SNRIs SSRIs TCAs Vincristine Vasodilators May exacerbate episodes Use with caution Moderate Weak of syncope in individuals with history of syncope ABBREVIATIONS: CrCl, creatinine clearance; SIADH, syndrome of inappropriate antidiuretic hormone secretion; SSRIs, selective serotonin reuptake inhibitors; SNRIs, serotonin-norepinephrine reuptake inhibitors; TCAs, tricyclic antidepressants.

First- and Second-Generation Antipsychotics1 First-Generation (Conventional) Agents Second-Generation (Atypical) Agents zz Chlorpromazine zz Aripiprazole zz Fluphenazine zz Asenapine zz Haloperidol zz Clozapine zz Loxapine zz Iloperidone zz Molindone zz Lurasidone zz Perphenazine zz Olanzapine zz Pimozide zz Paliperidone zz Promazine zz Quetiapine zz Thioridazine zz Risperidone zz Thiothixene zz Ziprasidone zz Trifluoperazine zz Triflupromazine

15 Drugs with Strong Anticholinergic Properties1 Antihistamines Anti-Parkinson Agents zz Brompheniramine zz Benztropine zz Carbinoxamine zz Trihexyphenidyl zz Chlorpheniramine zz Clemastine zz Cyproheptadine zz Dimenhydrinate zz Diphenhydramine zz Hydroxyzine zz Loratadine zz Meclizine Antidepressants Antipsychotics zz Amitriptyline zz Chlorpromazine zz Amoxapine zz Clozapine zz Clomipramine zz Fluphenazine zz Desipramine zz Loxapine zz Doxepin zz Olanzapine zz Imipramine zz Perphenazine zz Nortriptyline zz Pimozide zz Paroxetine zz Prochlorperazine zz Protriptyline zz Promethazine zz Trimipramine zz Thioridazine zz Thiothixene zz Trifluoperazine Antimuscarinics (Urinary Incontinence) Antispasmodics zz Darifenacin zz Atropine products zz Fesoterodine zz Belladonna alkaloids zz Flavoxate zz Dicyclomine zz Oxybutynin zz Homatropine zz Solifenacin zz Hyoscyamine products zz Tolterodine zz Loperamide zz Trospium zz Propantheline zz Scopolamine

16 Appendix 2

Legally Relevant Criteria for Decision-Making Capacity and Approaches to Assessment of the Patient2 Physician’s Assessment Questions for Criterion Patient’s Task Approach Clinical Assessment* Comments Communicate Clearly indicate Ask patient Have you decided whether to Frequent reversals of choice a choice preferred to indicate follow your doctor’s [or my] because of psychiatric or treatment a treatment recommendation for treatment? neurologic conditions may option choice Can you tell me what indicate lack of capacity that decision is? [If no decision] What is making it hard for you to decide? Understand Grasp the Encourage Please tell me in your own Information to be the relevant fundamental patient to words what your doctor understood includes nature information meaning of paraphrase [or I] told you about: of patient’s condition, nature information disclosed zz The problem with and purpose of proposed communicated information your health now treatment, possible benefits by physician regarding zz The recommended treatment and risks of that treatment, medical zz The possible benefits and alternative approaches condition and and risks (or discomforts) (including no treatment) treatment of the treatment and their benefits and risks zz Any alternative treatments and their risks and benefits zz The risks and benefits of no treatment Appreciate Acknowledge Ask patient to What do you believe is wrong Courts have recognized the situation medical describe views with your health now? that patients who do not and its condition of medical Do you believe that you need acknowledge their illnesses consequences and likely condition, some kind of treatment? (often referred to as “lack of consequences proposed insight”) cannot make valid of treatment treatment, and What is treatment likely decisions about treatment options likely outcomes to do for you? Delusions or pathologic What makes you believe levels of distortion or denial it will have that effect? are the most common What do you believe will causes of impairment happen if you are not treated? Why do you think your doctor has [or I have] recommended this treatment? Reason about Engage in Ask patient How did you decide This criterion focuses on treatment a rational to compare to accept or reject the the process by which a options process of treatment recommended treatment? decision is reached, not the outcome of the patient’s manipulating options and What makes [chosen option] choice, since patients the relevant consequences better than [alternative option]? information and to offer have the right to make reasons for “unreasonable” choices selection of option * Patients’ responses to these questions need not be verbal.

17 Screening for Depression Patient Health Questionnaire-2 (PHQ-2)3 1. In the past 12 months, have you ever had a time when you felt sad, blue, depressed, or down for most of the time for at least two weeks? 2. In the past 12 months, have you ever had a time, lasting at least two weeks, when you didn’t care about the things that you usually care about or when you didn’t enjoy the things that you usually enjoy? Interpretation of PHQ-2 If the patient answers YES to either question, then further evaluation by a primary care physician, geriatrician, or mental health specialist is recommended. NOTE: This screening test has not been validated in extremely frail elderly patients, those with severe concurrent medical illnesses, those who are suffering from medication side effects, or those with impaired communication skills.

Screening for Alcohol and Substance Abuse Modified Version of CAGE4-7 Ask the patient the following four questions: 1. Have you ever felt you should Cut down on your drinking or drug use? 2. Have people Annoyed you by criticizing your drinking or drug use? 3. Have you ever felt bad or Guilty about your drinking or drug use? 4. Have you ever had a drink or drug first thing in the morning E( ye-opener) to steady your nerves or to get rid of a hangover? Interpretation of Modified CAGE If YES to any of these questions, consider perioperative prophylaxis for withdrawal syndromes. If operation can be delayed, consider referring motivated patients to substance abuse specialist for preoperative abstinence or medical detoxification. Patients with alcohol use disorder should receive perioperative daily multivitamins (with folic acid) and high-dose oral or parental thiamine (100 mg).

Assessing Baseline and Current Functional Status in Ambulatory Patients Short Simple Screening Test for Functional Assessment8,9 Ask the patient the following four questions: 1. Can you get out of bed or chair yourself? 2. Can you dress and bathe yourself? 3. Can you make your own meals? 4. Can you do your own shopping? Interpretation of Functional Screening Test If NO to any of these questions, more in-depth evaluation should be performed, including full screening of ADLs and IADLs. Deficits should be documented and may prompt perioperative interventions (for example, referral to occupational therapy and/or physical therapy) and proactive discharge planning.

18 Assessing Gait and Mobility Impairment and Fall Risk in Ambulatory Patients10-12 Timed Up and Go Test (TUGT) Patients should sit in a standard armchair with a line 10 feet in length in front of the chair. They should use standard footwear and walking aids and should not receive any assistance. Have the patient perform the following commands: 1. Rise from the chair (if possible, without using the armrests) 2. Walk to the line on the floor (10 feet) 3. Turn 4. Return to the chair 5. Sit down again Interpretation of TUGT Any person demonstrating difficulty rising from the chair or requiring more than 15 seconds to complete the test is at high risk for falls. Consider preoperative referral to physical therapy for more detailed gait assessment.

Frailty Score: Operational Definition13 Criteria Definition Shrinkage Unintentional weight loss ≥10 pounds in past year Weakness Decreased grip strength Exhaustion Self-reported poor energy and endurance Low physical activity Low weekly energy expenditure Slowness Slow walking Interpretation of the Frailty Score The patient receives 1 point for each criterion met.

0–1 = Not Frail 2–3 = Intermediate Frail (Pre-frail) 4–5 = Frail

Frail patients are at much higher risk of adverse health outcomes. Intermediate frail patients are at elevated risk (less than frail ones) but are also at more than double the risk of becoming frail over 3 years.

19 Frailty Score14-15 Patient receives one point for each criterion (0–5) Frailty Criteria Definition Weight loss Unintentional weight loss ≥10 pounds in the past year. Decreased grip strength Grip strength in the lowest 20th percentile by gender and BMI. Three trials are (weakness) performed with a hand-held dynamometer and the average value is used. Men Women

BMI Kg Force BMI Kg Force ≤24 ≤29 ≤23 ≤17 24.1–26 ≤30 23.1–26 ≤17.3 26.1–28 ≤30 26.1–29 ≤18 >28 ≤32 >29 ≤21

Exhaustion For the following two statements: 1. “I felt that everything I did was an effort.” 2. “I could not get going.” The patient is asked: “How often in the last week did you feel this way?” 0 = rarely or none of the time (<1 day) 1 = some or a little of the time (1–2 days) 2 = a moderate amount of the time (3–4 days) 3 = most of the time The criterion is met if patient answers 2 or 3 to either statement. Low physical activity Weekly energy expenditure, determined with the short version of the Minnesota Leisure Time Activities Questionnaire in the lowest 20th percentile by gender: Men: <383 kcal/week. Women: <270 kcal/week. Slowed walking speed Walking speed in the lowest 20th percentile by gender and height. Time is measured for a distance of 15 feet at normal pace. The average of three trials is used. Men Women

Height Time Height Time ≤173 cm ≥7 sec ≤159 cm ≥7 sec >173 cm ≥6 sec >159 cm ≥6 sec

Screening for Severe Nutritional Risk16 Risk Factors for Severe Nutritional Risk zz BMI <18.5 kg/m2 zz Serum albumin <3.0 g/dL (with no evidence of hepatic or renal dysfunction) zz Unintentional weight loss >10%–15% within 6 months Interpretation of Nutritional Screening If YES to any above criterion, then the patient is at severe nutritional risk and should, if feasible, undergo a full nutritional assessment by a dietician to design a perioperative nutritional plan to address deficits.

20 Bibliography

Background and Introduction Bradburn E, Rogers FB, Krasne M, Rogers A, Horst MA, Belan MJ, Miller JA. High-risk geriatric protocol: Improving mortality in the elderly. J Trauma Acute Care Surg. August 2012;73(2):435-440.

Calland JF, Ingraham AM, Martin ND, Marshall GT, Schulman CI, Stapleton T, Barraco RD. Geriatric Trauma Update. Eastern Association for the Surgery of Trauma Workgroup. 2010. Available at: www.EAST.org. Accessed October 3, 2011.

Chow WB, Ko CY, Rosenthal RA, Esnaola NF, Merkow RP. Optimal Preoperative Assessment of the Geriatric Surgical Patient: A Best Practices Guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society.

Demetriades D, Karaiskakis M, Velmahos G, Alo K, Newton E, Murray J, Asensio J, Belzberg H, Berne T, Shoemaker W. Effect on outcome of early intensive management of geriatric trauma patients. Br J Surg. 2002;89:1319-1322.

Jacobs DG. Special considerations in geriatric injury. Curr Opin Crit Care. 2003;9:535-539.

Mangram AJ, Mitchell CD, Shifflette VK, Lorenzo M, Truitt MS, Goel A, Lyons MA, Nichols DJ, Dunn EL. Geriatric trauma service: A one-year experience. J Trauma Acute Care Surg. January 2012;72(1): 119-122.

Taylor MD, Tracy JK, Meyer W, Pasquale M, Napolitano L M. Trauma in the elderly: Intensive care unit resource use and outcome. J Trauma. 2002;53:407-414.

Trauma Team Activation Chang DC, Bass RR, Cornwell EE, Mackenzie EJ. Under triage of elderly trauma patients to state-designated trauma centers. Arch Surg. 2008;143:776-781.

Geriatric Trauma (Update). Available at: http://www.east.org/resources/treatment- guidelines/geriatric-trauma-(update). Accessed October 8, 2012.

Jacobs DG. Special considerations in geriatric injury. Curr Opin Crit Care. 2003;9:535-539.

Kohn MA, Hammel JM, Bretz SW, Stangby A. Trauma team activation criteria as predictors of patient disposition from the emergency department. Academic Emergency Medicine. 2004;11:1-9.

Rogers A, Rogers F, Bradburn E, Krasne M, Lee J, Wu D, Edavettal M, Horst M. Old and undertriaged: a lethal combination. Am Surg. June 2012;78(6):711-715.

Shifflette VK, Lorenzo M, Mangram AJ, Truitt MS, Amos JD, Dunn EL. Should age be a factor to change from a level II to a level I trauma activation? J Trauma. July 2010;69(1):88-92.

Initial Evaluation Callaway DW, Shapiro NI, Donnino MW, Baker C, Rosen CL. Serum lactate and base deficit as predictors of mortality in normotensive elderly blunt trauma patients. J Trauma. 2009;66:1040-1044.

Jacobs DG. Special considerations in geriatric injury. Curr Opin Crit Care. 2003;9:535-539.

Linzer M, Yang EH, Estes NA III, Wang P, Vorperian VR, Kapoor WN. Algorithm for the diagnosis of syncope. Part I: Value of history, physical examination, and electrocardiography. Clinical Efficacy Assessment Project of the American College of Physicians. Ann Intern Med. June 15, 1997;126(12):989-996.

McKinley BA, Marvin RG, Cocanuor CS, Marquez A, Ware DN, Moore FA. Blunt trauma resuscitation: The old can respond. Arch Surg. 2000;135:688-693.

Neideen T, Lam M, Brasel KJ. Preinjury beta blockers are associated with increased mortality in geriatric trauma patients. J Trauma. 2008;65:1016-1020.

Pieracci FM, Eachempati SR, Shou J, Hydo LJ, Barie PS. Degree of anticoagulation, but not warfarin use itself, predicts adverse outcomes after traumatic brain injury in elderly trauma patients. J Trauma. 2007;63:525-530.

21 Scalea TM, Simon HM, Duncan AO, Atweh NA, Sclafani SJ, Phillips TF, Shaftan GW. Geriatric blunt multiple trauma: Improved survival with early invasive monitoring. J Trauma. February 1990;30(2):129-134; discussion 134-136.

Smith DP, Enderson BL, Maull KI. Trauma in the elderly: Determinants of outcome. South Med J. February 1990;83(2):171-177.

Labs

COMORBIDS

Arnold TD, Miller M, van Wessem KP, Evans JA, Balogh. Base deficit from the first peripheral venous sample: a surrogate for arterial base deficit in the trauma bay. J Trauma. October 2011;71(4):793-797; discussion 797.

Blazer DG, Wu LT. The epidemiology of at-risk and binge drinking among middle-aged and elderly community adults: National Survey on Drug Use and Health. Am J Psychiatry. October 2009;166(10):1162-1169.

Bradburn E, DO, MS, Rogers FB, MD, MS, Krasne M, BS, et al. High-risk geriatric protocol: Improving mortality in the elderly. J Trauma Acute Care Surg. August 2012;73(2):435-440.

Callaway DW, Shapiro NI, Donnino MW, Baker C, Rosen CL. Serum lactate and base deficit as predictors of mortality in normotensive elderly blunt trauma patients. J Trauma. 2009;66:1040-1044.

Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. Optimal Preoperative Assessment of the Geriatric Surgical Patient: A Best Practices Guideline from the ACS National Surgical Quality Improvement Program.

Davis J, Kaups K. Base deficit in the elderly: A marker of severe injury and death. J Trauma. November 1998;45(5):873-877.

Harbrecht B, Rosengart M, Zenati M, Forsythe R, Peitzman A. Defining the contribution of renal dysfunction to outcome after traumatic injury. Am Surg. August 2007;73(8):836-840.

Ivascu FA, Howells GA, Junn FS, Bair HA, Bendick PJ, Janczyk RJ. Rapid warfarin reversal in anticoagulated patients with traumatic intracranial hemorrhage reduces hemorrhage progression and mortality. J Trauma. November 2005;59(5):1131-1137; discussion 1137-1139.

Lameire N, De Vriese A, Vanholder R. Prevention and nondialytic treatment of acute renal failure. Curr Opin in Crit Care. 2003;9:431-490.

Leblanc M, Kellum J, Gibney N, Lieberthal W, Tumlin J, Mehta R. Risk factors for acute renal failure: Inherent and modifiable risks. Current Opin Crit Care 2005;11:533-536.

Mangram AJ, Shifflette VK, Mitchell CD, Johnson VA, Lorenzo M, Truitt MS, Goel A, Lyons M, Dunn EL. The creation of a geriatric trauma unit “G-60.” Am Surg. September 2011;77(9):1144-1146.

Medications. Am J Emerg Med. February 2008;26(2):119-123.

Neideen T, Lam M, Brasel KJ. Preinjury beta blockers are associated with increased mortality in geriatric trauma patients. J Trauma. 2008;65:1016-1020.

CHRONIC MEDICAL CONDITIONS

Ansaloni L, Catena F, Chattat R, Fortuna D, Franceschi C, Mascitti P, Melotti RM. Risk factors and incidence of postoperative delirium in elderly patients after elective and emergency surgery. Br J Surg. February 2010;97(2):273-280.

Bergeron E, Clement J, Lavoie A, Ratte S, Bamvita JM, Aumont F, Clas D. A simple fall in the elderly: Not so simple. J Trauma. 2006;60:268-273.

Callaway DW, Wolfe R. Geriatric trauma. Emerg Med Clin N Am. August 2007;25(3):837-860.

Devereaux PJ, Goldman L, Cook DJ, Gilbert K, Leslie K, Guyatt GH. Perioperative cardiac events in patients undergoing noncardiac surgery: A review of the magnitude of the problem, the pathophysiology of the events and methods to estimate and communicate risk. Cmaj. September 13, 2005;173(6):627-634.

Dimick JB, Chen SL, Taheri PA, Henderson WG, Khuri SF, Campbell DA Jr. Hospital costs associated with surgical complications: A report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg. October 2004;199(4):531-537.

22 Fried LP, Ferrucci L, Darer J, Williamson JD, Anderson G. Untangling the concepts of disability, frailty, and comorbidity: implications for improved targeting and care. J Gerontol A Biol Sci Med Sci. March 2004;59(3):255-263.

Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci. March 2001;56(3):M146-156.

Johnson RG, Arozullah AM, Neumayer L, Henderson WG, Hosokawa P, Khuri SF. Multivariable predictors of postoperative respiratory failure after general and vascular surgery: Results from the patient safety in surgery study. J Am Coll Surg. June 2007;204(6):1188-1198.

Kaiser MJ, Bauer JM, Rämsch C, Uter W, Guigoz Y, Cederholm T, Thomas DR, Anthony PS, Charlton KE, Maggio M, Tsai AC, Vellas B, Sieber CC; Mini Nutritional Assessment International Group. Frequency of malnutrition in older adults: A multinational perspective using the mini nutritional assessment. J Am Geriatr Soc. September 2010;58(9):1734-1738.

Landesberg G, Beattie WS, Mosseri M, Jaffe AS, Alpert JS. Perioperative myocardial infarction. Circulation. June 9, 2009;119(22):2936-2944.

Lawrence VA, Hilsenbeck SG, Mulrow CD, Dhanda R, Sapp J, Page CP. Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery. J Gen Intern Med. December 1995;10(12):671-678.

Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, Sugarbaker DJ, Donaldson MC, Poss R, Ho KKL, Ludwig LE, Pedan A, Goldman L. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. September 7, 1999;100(10):1043-1049.

Manku K, Bacchetti P, Leung JM. Prognostic significance of postoperative in-hospital complications in elderly patients. I. Long-term survival. Anesth Analg. February 2003;96(2):583-589.

Marcantonio ER, Goldman L, Mangione CM, Ludwig LE, Muraca B, Haslauer CM, Donaldson MC, Whittemore AD, Sugarbaker DJ, Poss R, et al. A clinical prediction rule for delirium after elective noncardiac surgery. JAMA. January 12, 1994;271(2):134-139.

Nath B, Li Y, Carroll JE, Szabo G, Tseng JF, Shah SA. Alcohol exposure as a risk factor for adverse outcomes in elective surgery. J Gastrointest Surg. November 2010;14(11):1732-1741.

POISE Study Group, Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, Xavier D, Chrolavicius S, Greenspan L, Pogue J, Pais P, Liu L, Xu S, Málaga G, Avezum A, Chan M, Montori VM, Jacka M, Choi P. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): A randomised controlled trial. Lancet. May 31, 2008;371(9627):1839-1847.

Robinson TN, Eiseman B, Wallace JI, Church SD, McFann KK, Pfister SM, Sharp TJ, Moss M. Redefining geriatric preoperative assessment using frailty, disability and co-morbidity. Ann Surg. September 2009;250(3):449-455.

Robinson TN, Raeburn CD, Tran ZV, Angles EM, Brenner LA, Moss M. Postoperative delirium in the elderly: Risk factors and outcomes. Ann Surg. January 2009;249(1):173-178.

Rudolph JL, Inouye SK, Jones RN, Yang FM, Fong TG, Levkoff SE, Marcantonio ER. Delirium: An independent predictor of functional decline after cardiac surgery. J Am Geriatr Soc. April 2010;58(4):643-649.

Schiesser M, Kirchhoff P, Muller MK, Schafer M, Clavien PA. The correlation of nutrition risk index, nutrition risk score, and bioimpedance analysis with postoperative complications in patients undergoing gastrointestinal surgery. Surgery. May 2009;145(5):519-526.

Sterling DA, O’Connor JA, Bonadies J. Geriatric falls: Injury severity is high and disproportionate to mechanism. J Trauma. 2001;50:116-119.

Tonnesen H, Kehlet H. Preoperative alcoholism and postoperative morbidity. Br J Surg. July 1999;86(7):869-874.

23 Anticoagulation Bachelani AM, Bautz JT, Sperry JL, Corcos A, Zenati M, Billiar TR, Peitzman AB, Marshall GT. Assessment of platelet transfusion for reversal of aspirin after traumatic brain injury. Surgery. 2011;150:863-843.

Bechtel BF, Nunez TC, Lyon JA, Cotton BA, Barrett TW. Treatments for reversing warfarin anticoagulation in patients with acute intracranial hemorrhage: A structured literature review. International Journal of Emergency Medicine. 2011;4:40.

Cabral KP, Fraser GL, Gibbons BA, Hayes T, Florman JE, Seder DB. Prothrombin complex concentrates to reverse warfarin- induced coagulopathy in patients with intracranial bleeding. Clin Neurol Neurosurg. July 24, 2012. Epub ahead of print.

Campbell PG, Sen A, Yadia S, Jabbour P, Jallo J. Emergency reversal of antiplatelet agents in patients presenting with an intracranial hemorrhage: A clinical review. World Neurosurgery. 2010;74:279-285.

Collyer TC, Gray DJ, Sandhu R, Berridge F, Lyons G. Assessment of platelet inhibition secondary to clopidogrel and aspirin therapy in preoperative acute surgical patients measured by Thrombelastography Platelet Mapping. Br J Anaesth. 2009;102:492-498.

Cotton BA, McCarthy JJ, Holcomb JB. Acutely injured patients on dabigatran. N Engl J Med. 2011;365:2039-2040.

Ducruet AF, Hickman ZL, Zacharia BE, Grobelny BT, DeRosa PA, Landes E, Lei S, Khandji J, Gutbrod S, Connolly ES Jr. Impact of platelet transfusion on hematoma expansion in patients receiving antiplatelet agents before intracerebral hemorrhage. Neurol Res. 2010;32:706-710.

Ivascu FA, Janczyk RJ, Junn FS, Bair HA, Bendick PJ, Howells GA. Treatment of trauma patients with intracranial hemorrhage on preinjury warfarin. J Trauma. 2006;61:318-21.

Lavoie A, Ratee S, Clas D, Demers J, Moore L, Martin M, Bergeron E. Preinjury warfarin use among elderly patients with closed head injury in a trauma center. J Trauma. 2004;56:802-807.

Mina AA, Bair HA, Howells GA, Bendick PJ. Complications of preinjury warfarin use in the trauma patient. J Trauma. 2003;54:842-847.

Thaachil J, Gatt A, Martlew V. Management of surgical patients receiving anticoagulation and antiplatelet agents. British Journal of Surgery. 2008;95:1437-1448.

Patient Decision Making Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. April 4, 2002;346(14):1061-1066.

Mattimore TJ, Wenger NS, Desbiens NA, Teno JM, Hamel MB, Liu H, Califf R, Connors AF Jr, Lynn J, Oye RK. Surrogate and physician understanding of patients’ preferences for living permanently in a nursing home. J Am Geriatr Soc. July 1997;45(7):818-824.

McCahill LE, Dunn GP, Mosenthal AC, et al. Palliation as a core surgical principle: Part 2. J Am Coll Surg 2004;199:321-334.

Nierman DM, Schechter CB, Cannon LM, Meier DE. Outcome prediction model for very elderly critically ill patients. Crit Care Med. 2001;29:1853-1859.

Seckler AB, Meier DE, Mulvihill M, Paris BE. Substituted judgment: How accurate are proxy predictions? Ann Intern Med. July 15, 1991;115(2):92-98.

Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: A systematic review. Arch Intern Med. March 13, 2006;166(5):493-497.

Silveira MJ, Kim SY, Langa KM. Advance directives and outcomes of surrogate decision making before death. N Engl J Med. April 1, 2010;362(13):1211-1218.

Inpatient Management American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. February 29, 2012.

Barnett SR. Polypharmacy and perioperative medications in the elderly. Anesthesiol Clin. September 2009;27(3):377-389.

24 Biccard BM, Sear JW, Foex P. Statin therapy: A potentially useful peri-operative intervention in patients with cardiovascular disease. Anaesthesia. November 2005;60(11):1106 -1114.

Fleischmann KE, Beckman JA, Buller CE, et al. 2009 ACCF/AHA focused update on perioperative beta blockade. J Am Coll Cardiol. November 24, 2009;54(22):2102-2128.

Hajjar ER, Cafiero AC, Hanlon JT. Polypharmacy in elderly patients. Am J Geriatr Pharmacother. December 2007;5(4):345-351.

Stevens LA, Coresh J, Greene T, Levey AS. Assessing kidney function: Measured and estimated glomerular filtration rate. N Engl J Med. June 8, 2006;354(23):2473-2483.

Whinney C. Perioperative medication management: General principles and practical applications. Cleve Clin J Med. November 2009;76(4):S126-132.

Pain Ackroyd-Stolarz S, Mackinnon NJ, Sketris I, Sabo B. Potentially inappropriate prescribing of benzodiazepines for older adults and risk of falls during a hospital stay: A descriptive study. Can J Hosp Pharm. July 2009;62(4):276-283.

Demeure MJ, Fain MJ. The elderly surgical patient and postoperative delirium. J Am Coll Surg. November 2006;203(5):752-757.

Harrington DT, Phillips B, Machan J, Zacharias N, Velmahos GC, Rosenblatt MS, Winston E, Patterson L, Desjardins S, Winchell R, Brotman S, Churyla A, Schulz JT, Maung AA, Davis KA; Research Consortium of New England Centers for Trauma (ReCONECT). Factors associated with survival following blunt chest trauma in older patients: Results from a large regional trauma cooperative. Arch Surg. May 2010;145(5):432-437.

Lynch EP, Lazor MA, Gellis JE, Orav J, Goldman L, Marcantonio ER. The impact of postoperative pain on the development of postoperative delirium. Anesth Analg. April 1998;86(4):781-785.

Mohta M, Verma P, Saxena AK, Sethi AK, Tyagi A, Girotra G. Prospective, randomized comparison of continuous thoracic epidural and thoracic paravertebral infusion in patients with unilateral multiple fractured ribs--pilot study. J Trauma. April 2009;66(4):1096-1101.

Southworth S, Peters J, Rock A, Pavliv L. A multicenter, randomized, double-blind, placebo-controlled trial of intravenous ibuprofen 400 and 800 mg every 6 hours in the management of postoperative pain. Clin Ther. September 2009;31(9):1922-1935.

Delirium Ansaloni L, Catena F, Chattat R, Fortuna D, Franceschi C, Mascitti P, Melotti RM. Risk factors and incidence of postoperative delirium in elderly patients after elective and emergency surgery. Br J Surg. February 2010;97(2):273-280.

Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. Optimal preoperative assessment of the geriatric surgical patient: A best practice guideline from the ACS National Surgical Quality Improvement Program and the American Geriatrics Society. JACS. 2012. In press.

Hung WW, Egol KA, Zuckerman JD, Siu AL. Hip fracture management: Tailoring for the older patient. JAMA. May 23, 2012;307(20):2185-2194.

Robinson TN, Raeburn CD, Tran ZV, Angles EM, Brenner LA, Moss M. Postoperative delirium in the elderly: Risk factors and outcomes. Ann Surg. January 2009;249(1):173-178.

25 Rudolph JL, Jones RN, Levkoff SE, Rockett C, Inouye SK, Sellke FW, Khuri SF, Lipsitz LA, Ramlawi B, Levitsky S, Marcantonio ER. Derivation and validation of a preoperative prediction rule for delirium after cardiac surgery. Circulation. January 20, 2009;119(2):229-236.

Skelly JM, Guyatt GH, Kalbfleisch R, Singer J, Winter L. Management of urinary retention after surgical repair of hip fracture. CMAJ. April 1, 1992;146(7):1185-1189.

Complications Chow WB, Rosenthal RA, Merkow RP, Ko CY, Esnaola NF. Optimal preoperative assessment of the geriatric surgical patient: A best practice guideline from the ACS National Surgical Quality Improvement Program and the American Geriatrics Society. JACS. 2012. In press.

Fife D, Kraus J. Infection as a contributing cause of death in patients hospitalized for motor vehicle trauma. Am J Surg. 1988;155:278-283.

Stulberg JJ, Delaney CP, Neuhauser DV, Aron DC, Fu P, Koroukian SM. Adherence to surgical care improvement project measures and the association with postoperative infections. JAMA. 2010;303(24):2479-2485.

Specialized Geriatric Inpatient Care Ellis G, Whitehead MA, O’Neill D, Langhorne P, Robinson D. Comprehensive geriatric assessment for older adults admitted to hospital. Cochrane Database Syst Rev. July 6, 2011;(7):CD006211.

McCusker J, Bellavance F, Cardin S, Trepanier S, Verdon J, Ardman O. Detection of older people at increased risk of adverse health outcomes after an emergency visit: The ISAR screening tool. J Am Geriatr Soc. 1999;47:1229-1237.

Lenartowicz M, Parkovnick M, McFarlan A, Haas B, Straus SE, Nathens AB, Wong CL. An evaluation of a proactive geriatric trauma consultation service. Annals of Surgery. In press.

Discharge Adunsky A, Lusky A, Arad M, Heruti RJ. A comparative study of rehabilitation outcomes of elderly hip fracture patients: The advantage of a comprehensive orthogeriatric approach. J Gerontol A Biol Sci Med Sci. June 2003;58(6):542-547.

Carillo EH, Richardson JD, Malias MA, Cryer HM, Miller FB. Long term outcome of blunt trauma in the elderly. Surg Gynecol Obstet. 1993;176:559-564.

Fallon WF Jr., Rader E, Zyzanski S, Mancuso C, Martin B, Breedlove L, DeGolia P, Allen K, Campbell J. Geriatric outcomes are improved by a geriatric trauma consultation service. J Trauma. November 2006;61(5):1040-1046.

Fife D, Kraus J. Infection as a contributing cause of death in patients hospitalized for motor vehicle trauma. Am J Surg. 1988;155:278-283.

McGwin G, MacLennan PA, Fife JB, Davis GG, Rue LW III. Preexisting conditions and mortality in older trauma patients. J Trauma. June 2004;56(6):1291-1296.

McKevitt EC, Calvert E, Ng A, Simons RK, Kirkpatrick AW, Appleton L, Brown DR. Geriatric trauma: Resource use and patient outcomes. Can J Surg. June 2003;46(3)211-215.

Soberg HL, Bautz-Holter E, Roise O, Finset A. Long-term multidimensional functional consequences of severe multiple injuries two years after trauma: A new admission longitudinal cohort study. J Trauma. February 2007;62(2):461-470.

Van Aalst JA, Morris JA, Yates HK, Miller RS, Bass SM. Severely injured geriatric patients return to independent living: A study of factors influencing function and independence. J Trauma. 1991;31:1096-1101.

26 References

Appendices 1. American Geriatrics Society Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults. J Am Geriatr Soc. February 29, 2012.

2. Appelbaum PS. Clinical practice. Assessment of patients’ competence to consent to treatment. N Engl J Med. November 1, 2007;357(18):1834-1840.

3. Li C, Friedman B, Conwell Y, Fiscella K. Validity of the Patient Health Questionnaire 2 (PHQ-2) in identifying major depression in older people. J Am Geriatr Soc. April 2007;55(4):596-602.

4. Hinkin CH, Castellon SA, Dickson-Fuhrman E, Daum G, Jaffe J, Jarvik L. Screening for drug and alcohol abuse among older adults using a modified version of the CAGE. Am J Addict. Fall 2001;10(4):319-326.

5. Beullens J, Aertgeerts B. Screening for alcohol abuse and dependence in older people using DSM criteria: A review. Aging Ment Health. January 2004;8(1):76-82.

6. Berks J, McCormick R. Screening for alcohol misuse in elderly primary care patients: A systematic literature review. Int Psychogeriatr. December 2008;20(6):1090-1103.

7. McGrath A, Crome P, Crome IB. Substance misuse in the older population. Postgrad Med J. April 2005;81(954):228-231.

8. Woolger JM. Preoperative testing and medication management. Clin Geriatr Med. November 2008;24(4):573-583, vii.

9. Lachs MS, Feinstein AR, Cooney LM Jr., Drickamer MA, Marottoli RA, Pannill FC, Tinetti ME. A simple procedure for general screening for functional disability in elderly patients. Ann Intern Med. May 1, 1990;112(9):699-706.

10. Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. January 2011;59(1):148-157.

11. Gunter KB, White KN, Hayes WC, Snow CM. Functional mobility discriminates nonfallers from one-time and frequent fallers. J Gerontol A Biol Sci Med Sci. November 2000;55(11):M672-676.

12. Podsiadlo D, Richardson S. The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. February 1991;39(2):142-148.

13. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci. March 2001;56(3):M146-156.

14. Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: Evidence for a phenotype. J Gerontol A Biol Sci Med Sci. March 2001;56(3):M146-156.

15. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. June 2010;210(6):901-908.

16. Weimann A, Braga M, Harsanyi L, Laviano A, Ljungqvist O, Soeters P; DGEM (German Society for Nutritional Medicine), Jauch KW, Kemen M, Hiesmayr JM, Horbach T, Kuse ER, Vestweber KH; ESPEN (European Society for Parenteral and Enteral Nutrition). ESPEN Guidelines on Enteral Nutrition: Surgery including organ transplantation. Clin Nutr. April 2006;25(2):224-244.

27 Expert Panel

H. Gil Cryer, MD, FACS (Chair) Professor of Surgery, Trauma/Emergency Surgery and Critical Care Program, UCLA, Los Angeles, CA

J. Forrest Calland, MD, FACS Assistant Professor of Surgery, University of Virginia Health System, Richmond, VA

Warren Chow, MD James C. Thompson Geriatrics Surgical Fellow, American College of Surgeons, Chicago, IL

Matthew Davis, MD, FACS Trauma Program Director, Scott and White Memorial Hospital, Temple, TX

Mark Hemmila, MD, FACS Associate Professor of Surgery, University of Michigan Health Systems, Ann Arbor, MI

Rosemary Kozar, MD, FACS Professor of Surgery and Chief of Trauma, Memorial Hermann Hospital, Houston, TX

Sheila Lopez Director of Trauma Service, Memorial Hermann Hospital, Houston, TX

Alicia Mangram, MD, FACS Medical Director of Trauma Services, John C. Lincoln Hospital, Phoenix, AZ

Gary Marshall, MD Professor of Surgery, University of Pittsburg Medical Center, Pittsburg, PA

Avery B. Nathens, MD, FACS Professor of Surgery, University of Toronto, Surgeon in Chief of Department of Surgery, Sunnybrook Hospital, Toronto, ON

Ronnie Rosenthal, MD Professor of Surgery, Yale University, Chief of Surgery of VA Connecticut Healthcare System, West Haven, CT

Areti Tillou, MD, MSEd Assistant Professor of Surgery David Geffen School of Medicine, UCLA, Los Angeles, CA

Camillia Wong, MD Assistant Professor, University of Toronto, Geriatrician and Associate Scientist, St. Michael’s Hospital, Toronto, ON

The American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) Best Practices Guidelines have been developed for quality improvement purposes. The documents may be downloaded and printed for personal use by health care professionals, and may also be used in quality improvement initiatives or programs. The documents may not be distributed for profit without the written consent of the American College of Surgeons.

The intent of the ACS TQIP Best Practices Guidelines is to provide health care professionals with evidence-based recommendations regarding care of the geriatric trauma patient. The Best Practices Guidelines do not include all potential options for prevention, diagnosis, and treatment and are not intended as a substitute for the provider’s clinical judgment and experience. The responsible provider must make all treatment decisions based upon his or her independent judgment and the patient’s individual clinical presentation. The ACS shall not be liable for any direct, indirect, special, incidental, or consequential damages related to the use of the information contained herein. The ACS may modify the TQIP Best Practices Guidelines at any time without notice.

28 Notes

29 Notes

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